Stress urinary incontinence (SUI) is the involuntary loss of urine with increased intra-abdominal pressure in the absence of a bladder contraction. Epidemiological studies have shown it to be the most common type of incontinence overall, particularly among young women under age 50.¹ Pregnancy and childbirth are the biggest risk factors for the development of SUI. Several mechanisms of pelvic floor insult have been studied including neural, levator ani and fascial injury. Nonetheless, the pregnancy and childbirth-related mechanism of injury to the pelvic floor directly leading to SUI has not been fully elucidated. The risk of SUI is increased regardless of modality of childbirth; however, vaginal delivery carries a higher risk than cesarean section.² The increased risk of SUI with vaginal delivery over cesarean section has been substantiated by a meta-analysis of 15 studies which found a 1.85 increased odds ratio.³ This has led to the widely held opinion that it is best to postpone surgical treatment for SUI until no future pregnancies are desired or women are post-reproductive age. Furthermore, some obstetricians will recommend elective cesarean section in cases where the patient has previously undergone SUI surgery.⁴ However, is this widely held recommendation in fact necessary and are we doing a disservice to patients who are still in their child-bearing years by postponing SUI surgery as a treatment option?

The first question to resolve is to determine the safety of pregnancy after SUI operation. A systematic review included The Journal of Urology^® looked at this very question and published their findings in 2012. The review included 20 articles comprising 118 patients who had previously undergone an SUI operation of any kind prior to index pregnancy and delivery. Urinary retention developed during pregnancy in 2 patients, 1 of which subsequently developed pyelonephritis that did not result in a complication of the pregnancy. The authors concluded that there may exist a low risk of urinary retention during pregnancy in patients who have previously undergone SUI surgery. Nevertheless, given the minimal increased risk, sling operation may still be considered appropriate in patients who wish to have children later.⁵ In 2016, a retrospective series of 26 patients who had become pregnant and delivered a child after previously undergoing midurethral sling (MUS) operation for SUI found no sling-related pregnancy or childbirth complications.⁶

What about the risk of SUI recurrence and repeat surgery with pregnancy/childbirth after previous SUI surgery? MUSs have been the most extensively studied surgical treatment for SUI.⁷ A population-based cohort study from Sweden assessed whether subsequent childbirth affects the outcome of MUS surgery. The primary measure was patient-reported, symptomatic SUI recurrence. The study group consisted of 163 patients who had subsequent childbirth either vaginally or via cesarean section after index MUS surgery. This group was matched by age and year of index MUS surgery to a control cohort of 374 patients who did not have subsequent childbirth after index MUS surgery. There was no significant difference in patient reported recurrent SUI on multivariate analysis between the study and control groups. Furthermore, vaginal delivery as compared to cesarean section did not increase the risk of recurrent SUI. The authors thus concluded that childbirth of any modality is not associated with an increased risk of SUI recurrence after previous MUS surgery.⁸

A similar study out of Finland included 94 study patients and 330 matched controls who had undergone retropubic or transobturator sling. The primary endpoint was incidence of repeat SUI surgery. Comparable to the Swedish study, there was no significant difference in the incidence of repeat SUI surgery performed between the study and control groups. Pregnancy and delivery do not increase the odds for SUI reoperation or SUI revisit.⁹

SUI is the most common pelvic floor complaint in postpartum women. We know that urinary incontinence is distressing and can have detrimental effects on patients’ psychosocial well-being and overall quality of life.¹⁰ Women are also postponing childbirth to later in life. Since age is another notable risk factor for prevalence and severity of incontinence,¹¹ it is not surprising that the burden of SUI has increased with the trend in delayed childbearing.¹² We are doing a disservice to these patients by insisting they postpone SUI surgery until after childbearing. The evidence suggests that it is safe to proceed with SUI surgery if the patient elects, independent of their future pregnancy plans. Pregnancy is safe after any SUI surgery. After SUI surgery, the incidence of SUI recurrence or reoperation does not appear to increase with subsequent childbirth of any modality.